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Irish Syllabus: Perioperative medicine & clinical skills

Created: 20/4/2004


Cyanosis, hypoxia, laryngospasm & bronchospasm occurring during induction, maintenance or recovery
Failed intubation
Difficulty with intermittent positive pressure ventilation and sudden or progressive loss of minute volume
Sudden or progressive increase in peak inspiratory pressure
Tension pneumothorax
Aspiration; on induction, extubation, in recovery, when unconscious
Increasing end-tidal CO2
Suddenly decreasing end-tidal CO2
Air/CO2/fat embolism
Rapidly increasing hypertension
Sudden hypotension
Progressively worsening  sinus tachycardia
Sudden ECG  changes: ST segment, tachydysrhythmia, bradycardia, ventricular extrasystoles – ventricular tachycardia – ventricular fibrillation
Sudden convulsion; on induction, with caudal/epidural/spinal, in recovery
High spinal
Malignant hyperpyrexia
Mismatched transfusion
Sudden cuff deflation during intravenous regional anesthesia
Inadvertent intra-arterial injection of irritant


Recognition and diagnosis of causes of cardiorespiratory arrest
Causes of cardiorespiratory arrest during induction, maintenance and recovery from anaesthesia
Recognition and management of non-cardiac causes of cardiorespiratory arrest
Knowledge of specific problems of paediatric resuscitation
Equipment checklist
Life support algorithms
Methods of airway management; mouth-mouth/nose, bag & mask, laryngeal mask airway, intubation
Method of chest compression
Vascular access
Fluid balance assessment/management
Arrhythmia recognition and management with drugs, defibrillator, pacemaker
Defibrillation and defibrillator settings
Deciding when further efforts are futile, ethical aspects
Diagnosis of death


Knowledge required:
Implications for anaesthesia of more common elective conditions requiring gynaecological, abdominal, orthopaedic, ENT, dental, urological and body surface surgery. Knowledge of sub-specialty practice and specialised techniques is not required unless specified elsewhere.
The relevance of trauma, intestinal obstruction and acute abdominal emergencies.
The ASA classification and other scoring systems such as Glasgow coma scale (GCS)
The interpretation of relevant preoperative investigations
Restriction of food and fluid by mouth, cessation of smoking, correction of dehydration
Assessment of difficulties in airway management and the importance of the 'shared airway'
Implications for anaesthesia of common medical conditions (ischaemic heart disease [IHD], hypertension, diabetes, asthma, rheumatoid arthritis etc)
Anaesthetic implications of current drug therapy and whether it should be continued, modified, stopped or changed perioperatively
Need for and methods of perioperative antithrombotic treatment
The importance of an anaesthetic history and genetic diseases in anaesthesia with respect to suxamethonium apnoea, anaphylaxis and malignant hyperpyrexia
Assessment of postoperative analgesic needs
Assessment of whether ICU or HDU care will be required postoperatively
The importance of consent and the issues surrounding it
Dangers of repeat anaesthesia

Experience to be gained:
Histrory taking:
Anaesthetic history, personal and familial
Previous airway/intubation difficulties
Medication, current and past
Allergies and previous drug reactions
Tobacco and alcohol consumption
Previous anaesthetic exposure and surgery
Respiratory status and symptoms (especially chronic obstructive airways disease [COPD] & asthma)
Cardiovascular status and symptoms (especially IHD & hypertension)
Neurological status and symptoms (especially epilepsy, cerebrovascular accident [CVA], level of consciousness and mental state)
Gastrointestinal (GI) problems (especially reflux, obstruction, possible delayed gastric emptying)
Arthropathies and other musculo-skeletal disorders (especially rheumatoid arthritis)
Renal conditions
Hepatic conditions (especially jaundice, cirrhosis)
Endocrine conditions (especially steroid therapy, diabetes)
Skin conditions
Obstetric conditions
Hereditary & congenital disorders affecting anaesthesia
Nutritional abnormalities (obesity)
Social problems and identification of groups who pose a high infection risk

Physical examination

Teeth/airway/cervical spine/intubation assessment
Cardiovascular system (IHD, hypertension, left ventricular failure)
Respiratory system (asthma, COPD)
Nutritional state (obesity)
Neurological system (GCS: any acute or residual effects of CVA)
Abdomen and GI tract
Sequelae of diabetes and steroids
Musculo-skeletal problems (including relevance to positioning, neck stability, regional

Data interpretation

Respiratory function tests
Central venous pressure measurement
Systolic, diastolic and mean arterial pressure
Exercise tests
Interpreting fluid balance and other charts

Radiological (showing clear abnormalities):
Chest radiographs
Films showing long bone, skull, vertebral and rib fractures
Simple CAT and MRI scans of head demonstrating fractures/haemorrhage
Neck and thoracic inlet films
Films showing abdominal fluid levels/air

Haematology (including coagulation and sickle tests)
Urea and electrolytes
pH and blood gases
Liver function tests
Thyroid function

Special groups

Children (aged 5 years and over)
The elderly
Day case patients


Deciding on an anaesthetic technique appropriate to the findings
Ensuring the necessary resources are available for safe patient care


Consent for:
 - general anaesthesia (including a discussion of the risks)
 - epidural/caudal/spinal/regional/local blocks ((including a discussion of the risks)
Explanation of need for preoperative routine and specialised tests (including hepatitis
screening, HIV testing and sickle cell status)
Explanation of pain management, side-effects and complications of:
 - oral/sublingual/rectal/subcutaneous/IM/IV/nasal/transdermal drugs
 - epidural/regional techniques/local blocks
 - inhalational analgesia
 - patient-controlled analgesia (PCA)
Discussion of preoperative medication choices
Explanation of postoperative expectations and care
Communication with other professionals


Knowledge required:
Rationale for use of premedicant drugs
Choice of drugs, advantages and disadvantages
Rationale for antacid and prokinetic premedication
Rationale for antithrombotic therapy
Understanding of causes of delayed gastric emptying

Experience to be gained:
Assessment of level of anxiety and addressing patient's concerns
Recognition of situations leading to delayed gastric emptying
Checking a patient prior to premedication and on arrival in the anaesthetic room/theatre

Special groups

Children (aged 5 years and over)
The elderly
Day case patients
The acutely ill


Ability to reassure patient and allay anxiety
Explain (as appropriate) problems/complications to patients/ relatives concerning:
 - difficult intubation & dentition
 - sore throat, nausea and vomiting
 - thrombophlebitis
 - post-spinal headache
 - suxamethonium apnoea and pains
 - anaphylaxis
 - malignant hyperpyrexia


Knowledge required:
Intravenous and inhalational induction of anaesthesia; advantages and disadvantages of each technique
Indications for tracheal intubation
Selection of tube type (oral, nasal, armoured etc), diameter and length
Management of difficult intubation and failed intubation
Methods of confirming placement of the endotracheal tube; oesophageal and endobronchial intubation, complications
Insertion and use of oral airways, face masks and laryngeal mask airway
Causes of regurgitation and vomiting during induction, prevention and management of pulmonary aspiration
Cricoid pressure
Induction of anaesthesia in special circumstances, (head injury, full stomach, upper airway obstruction, shock)
Drugs: pharmacology and dosages of induction agents, relaxants, analgesics and inhalational agents
Side-effects of drugs used and their interactions
Monitoring during induction
Recognition and management of anaphylactic and anaphylactoid reactions, including follow-up and patient information
Management of intra-arterial injection of harmful substances (e.g. antibiotics, thiopentone)
Management of asthma, COPD, hypertension, IHD, rheumatoid arthritis
Problems of the obese patient

Experience to be gained:
IV and inhalational induction of anaesthesia in patients with elective and urgent conditions requiring gynaecological, abdominal, orthopaedic, ENT, dental, urological and body surface surgery. (Knowledge of sub-specialty practice and specialised techniques is not required unless specified elsewhere).
Checking patient into the anaesthetic room or theatre
Safety checking of equipment
Obtaining vascular access - suitability of sites and technique of intravenous injection
Airway assessment and optimising the patient’s position for airway management
Airway management with mask and oral/nasal airways
Introduction and checking correct placement of laryngeal mask airway
Appropriate choice and passage of oral and nasal endotracheal tubes
Intubation up to grade II Cormack-Lehane
Use of gum elastic bougie and stilette
Identifying correct/incorrect placement of tube (oesophagus/main bronchus)
Interpretation of capnograph trace
Failed intubation drill
Rapid sequence induction/cricoid pressure
Checking difficult intubation kit and paediatric intubation set
Use of monitoring equipment, including application of ECG electrodes
Managing of cardiovascular and respiratory changes during and after induction of general anaesthesia


Safety first
Always knowing the whereabouts of senior assistance
Being clear in explanations to patient and staff
Being reassuring to patients during induction of anaesthesia
Being polite, calm and having a professional approach


Knowledge required:
Techniques of maintenance of general anaesthesia involving both spontaneous and controlled ventilation (except sub-specialty and highly specialised practice)
Definition of and methods of sedation
Management of the shared airway
Effects and hazards of the pneumoperitoneum induced for laparoscopic surgery
Drugs: pharmacology, uses and dosages of induction agents used for IV maintenance, relaxants, analgesics, inhalational agents
Methods of producing muscle relaxation
Choice of spontaneous and controlled ventilation and methods of monitoring them
Minimum monitoring standards
Additional monitoring for sick patients (e.g. central venous pressure, urine flow)
Detection and prevention of awareness
Management of important critical incidents occurring during anaesthesia (Module 1)
Diagnosis and treatment of pneumothorax
Principles of fluid balance
Blood & blood products; synthetic colloids; crystalloids
Management of massive haemorrhage, volume expansion, blood transfusion (hazards including incompatibility reaction)
Correct intraoperative positioning on theatre table, care of pressure points, avoidance of nerve injury: complications of supine and prone positions
Management of asthma, COPD, hypertension, IHD, rheumatoid arthritis, jaundice, steroid therapy, diabetes
Content of the anaesthetic record
Modification of technique in repeat anaesthesia
Understanding basic surgical operations

Experience to be gained:
Maintenance of appropriate levels of anaesthesia with inhalational and intravenous agents in patients with elective and urgent conditions requiring gynaecological, abdominal,
orthopaedic, ENT, dental, urological and body surface surgery. Knowledge of sub-specialty practice and specialised techniques is not required unless specified elsewhere
Transferring the patient from trolley to operating table
Positioning the patient
Airway control: recognition and correction of problems
Laryngoscopy and intubation and its problems
Detection and correction of airway obstruction
Use of oral airways, facemasks and laryngeal mask airway
Sharing the airway
Management of appropriate intermittent positive pressure ventilation
Methods of pain relief during maintenance
Management of effects of drugs used during anaesthesia
Management of hypo- and hypertension
Provision of intraoperative fluids; transfusion of blood and blood products
Management of diabetes
Methods of detection of awareness
Management of appropriate muscle relaxation.
Management of any critical incidents which occur during anaesthesia
Interpretation and limitations of monitoring equipment


Knowledge required:
Causes and treatment of failure to breathe at end of operation
Distinguishing between opiate excess, continued anaesthetic effect and/or residual paralysis
Care of the unconscious patient
Monitoring the patient in recovery
Interpretation of nerve stimulator patterns
Oxygen therapy, indications and techniques
Management of cyanosis, hypo- and hypertension, shivering and stridor
Postoperative fluid balance and prescribing
Assessment of pain and methods of pain management
Methods of treating postoperative nausea and vomiting
Causes and management of postoperative confusion
Management of asthma, COPD, hypertension, IHD, rheumatoid arthritis, jaundice, steroid therapy, diabetes
Management of the obese patient
Recovery room equipment
Prevention, diagnosis and management of postoperative pulmonary atelectasis, deep vein thrombosis and pulmonary embolus
Criteria for discharge of day-stay patients

Experience to be gained:
Recovery from anaesthesia in patients with elective and urgent conditions requiring gynaecological, abdominal, orthopaedic, ENT, dental, urological and body surface surgery. Knowledge of sub-specialty practice and specialised techniques is not required unless
specified elsewhere
Clear instructions during handover of patient to recovery staff
Assessment of full return of protective reflexes
Assessment of adequacy of ventilation/reversal
Recognition of residual relaxant action
Use of nerve stimulator
Extubation and airway protection in presence of potentially full stomach
Prescription of postoperative fluids
Assessment of fluid balance and need for urethral catheterisation
Evaluation and management of postoperative confusion
Assessment of postoperative pain
Prescription of postoperative pain regimen
Treatment of nausea and vomiting
Stabilisation before discharge from Recovery
Continuation of care until discharge from Recovery, and beyond as appropriate
Criteria for discharge of patients to ward
Criteria for discharge of day-stay patients


Clear communication
Rapid response to calls for help
Follow-up of sick patients on the ward before going home


Knowledge required:
An understanding of the potential benefits of high dependency and intensive care
Common causes of admission to high dependency and intensive care
Method of examination of the unconscious patient
The principles of brain stem death diagnosis
An understanding of sepsis and the basic patterns of failure of the major organs
The common causes of cardiac and respiratory arrest
The anatomy of the oropharynx, larynx, trachea & bronchial tree
Basic anatomy of neck, upper thorax, arms, wrists, inguinal region and foot relevant to securing venous and arterial access
Method of inserting a chest drain and relief of tension pneumothorax
Understanding of the pharmacology and  choice of intravenous fluids appropriate for use in major fluid loss
The recognition of basic cardiac dysrrhythmias and the current therapies (physical [carotid sinus massage], electrical [defibrillation & countershock], electrolytic [Mg++,
Ca++] and pharmacological [adrenaline, atropine, lidocaine and 2nd line drugs])
Pharmacology of the common inotropes, major analgesics, muscle relaxants and sedative and anaesthetic induction agents used in the critically ill, including their common side-effects and contraindications
Thromboprophylaxis in intensive and high dependency patients
Choice of antibiotics
Use of diuretics for cardiac and respiratory failure and to maintain urine output
Basic cardiac physiology
Basic physiology of respiration and the consequences of positive pressure ventilation
An understanding of common blood gas abnormalities
An understanding of  mechanical lung ventilation in use in critically ill patients, with:
 - a knowledge of the vocabulary
 - an understanding of the uses and limitations of monitoring equipment
 - a knowledge of the content of an ICU record
 - an insight into likely outcome based upon severity scoring
 - a knowledge of the grief response

Experience to be gained:
Cardiopulmonary resuscitation
Maintenance of a clear airway using bag and mask
Insertion of an endotracheal tube, via the oral route
Examination and care of the unconscious patient
Insertion of adequate peripheral venous access sufficient to manage major haemorrhage
Insertion of central venous and arterial cannulae
Institution and maintenance of controlled mechanical ventilation in a critically ill patient
Ability to summarise and provide a succinct analysis of the patient’s medical history, ongoing therapies and expected problems to medical and nursing colleagues
Good communication with patients, relatives and staff


Understanding of the needs and behaviour of worried and grieving relatives
Commitment to good communication
Willingness to accept failures of therapy
Involving others with specialist skills
Recognition of team approach


Knowledge required:
Pharmacology of local anaesthetics & spinal opioids
Anatomy of spine, nerve roots, cauda equina, intercostal nerves, brachial plexus, femoral nerve, inguinal canal, nerves at wrist and ankle, nerve supply of larynx
Dermatomes and levels for common operations (e.g. inguinal hernia, haemorrhoids)
Technique of spinal and epidural (including caudal) anaesthesia: single shot and catheter techniques
Management of the complications of spinal and epidural (including caudal) analgesia (associated hypotension, shivering, nausea & anxiety)
Management of accidental total spinal blockade
Management of dural tap
Techniques and complications of intravenous regional anaesthesia (IVRA),
Toxicity of local anaesthetic agents and its management
Management of failed/deteriorating regional block
Methods of sedation
Absolute and relative contraindications to regional blockade

Experience to be gained:
Technique of spinal and epidural (including caudal) analgesia in any suitable patients
Recognition of contraindicated or unsuitable patients or those in whom a block would be difficult to perform
Management of hypotension, nausea, anxiety and shivering induced by spinal or epidural blockade
Postoperative care following spinal or epidural block (including urinary retention)
Prescription of continuous epidural infusions
Use of epidural techniques for postoperative pain management
Checking epidural/spinal packs
Technique of IVRA
Performance of some simple peripheral nerve blocks
Use of drugs to provide sedation
Combined general and regional anaesthesia


Safety first
Considering views of patient and surgeon
Management of theatre environment with awake patient
Planning list to allow block to take effect
Communication and reassurance
Consent for regional blockade


Knowledge required:
Performance and interpretation of the primary and secondary survey
Emergency airway management
Anatomy and technique of cricothyrotomy/tracheostomy/mini-tracheotomy
Establishing IV access: interosseous cannulation
Immediate specific treatment of life-threatening illness or injury, with special reference to thoracic and abdominal trauma
Recognition and management of hypovolaemic shock
Effects of trauma on gastric emptying
Central venous access: anatomy and techniques
Central venous pressure monitoring
Arterial pressure monitoring
Pleural drain insertion
Peritoneal lavage
Principles of the management of head injury
Mechanisms and effects of raised intracranial pressure: coup and contra-coup injuries
Methods of preventing the 'second insult' to the brain
Principles of anaesthesia in the presence of a recent head injury
Management of cervical spine injuries
Principles of the safe transfer of patients
Understanding portable monitoring systems
Recognition and management of dilutional coagulopathy
Factors affecting intraocular pressure

Experience to be gained:
Assessment and immediate management of trauma patient: primary and secondary survey
Glasgow coma scale
Recognition of need for appropriate investigations (Hb, cross-match, chest X-ray etc)
Assessment and management of circulatory shock
Emergency airway management, oxygen therapy and ventilation
Chest drain insertion and management: emergency relief of tension pneumothorax
Cannulation of major vessels for resuscitation and monitoring
Care and immobilisation of cervical spine
Transfers within and between hospitals of adults who do not have life-threatening conditions or a severe head injury
Analgesia for trauma victim
Urinary catheterisation in traumatised patient
Establishing central venous pressure monitoring: interpretation of readings
Establishing arterial pressure monitoring: interpretation of readings
Anaesthesia in the presence of a recent head injury (which itself does not require surgery)
Anaesthesia for a penetrating eye injury
Ability to deal with emergencies before, during and after anaesthesia and the ability to stabilise a patient's condition until senior assistance arrives


Importance of speed of response and proper resuscitation
Try to offer the best chance of survival
Focus on the golden hour
Communication with appropriate specialists
Ability to take control when either appropriate or necessary
Insist on stabilisation before transfer
Pretransfer checking of kit and personnel
Communication with relatives


Physiological changes associated with a normal pregnancy
Functions of the placenta: placental transfer: foeto-maternal circulation
The foetus: foetal circulation: changes at birth
Pain pathways relevant to labour
Methods of analgesia during labour: indications and contraindications
Effect of pregnancy on the technique of general and regional anaesthesia
Principles of anaesthesia for incidental surgery during pregnancy
Preoperative assessment of pregnant patient
Anaesthesia for retained products of conception
Analgesia for labour
Management of antepartum haemorrhage and primary pulmonary hypertension
Management of dilutional coagulopathy
Intubation problems in the full-term mother
Anaesthesia/analgesia for instrumental delivery
Anaesthesia for retained placenta
Anaesthesia for caesarean section


Attempt by conscientious care to recognise problems early
Seek senior help early
Good communication with mother, partner and other family members
Calmness under pressure
Timely assistance and prompt response to requests for analgesia and help
Reassurance to the mother
Compassion and kindness when the outcome of labour has been poor


Anatomical differences in the airway, head and spinal cord from the adult
Deciduous and permanent dentition
Physiological differences from the adult
Haematological and biochemical changes with age
Estimation of blood volume, replacement of fluid loss
Modification of drug dosages
Analgesia for children
Premedication, including local anaesthesia for venepuncture
Calculation of tube sizes, selection of masks and airways
Choice of breathing system
Upper respiratory tract infections and when to cancel operations
Psychological aspects of sick children
Preoperative assessment of the previously fit child
Anaesthesia in fit children for elective and urgent general, ENT and ophthalmic surgery, minor trauma and other non-specialist procedures
Venous access (including local anaesthesia premedication)
Airway management, selection of correct sized tubes and masks etc
IV and gaseous induction of general anaesthesia
Spontaneous and ventilated maintenance of anaesthesia
Caudal and other simple blocks
Management and stabilisation of the injured child (excluding neonates and infants) until senior help arrives
Principles of paediatric resuscitation


Communication with the child and parents
Reassurance for the child and parents
Issues of consent
Management of the environment during induction of anaesthesia


Physiological changes with age
Altered pharmacological response
Erosion of physiological reserve
Frequent co-morbidities
Positioning difficulties
Communication difficulties (eyesight, hearing, CVAs)
Mental clarity, memory loss
Causes of postoperative confusion
Importance of social circumstances
Modifications necessary when anaesthetising the elderly
Management of postoperative confusion


Special efforts to communicate clearly (N.B. deafness and blindness)
Old people have feelings too
Respect for the social norms of older people
Problems of consent in mental infirmity
Recognising the limitations of therapy
Ethics of 'do not resuscitate' orders


Afferent nociceptive pathways, dorsal horn, peripheral and central mechanisms, neuromodulatory systems, supraspinal mechanisms
Nociceptive pain, visceral pain, neuropathic pain
Influence of therapy on nociceptive mechanisms
The analgesic ladder
Measurement of pain
Assessment and management of postoperative pain and nausea
Monitoring acute pain and pain-relieving methods
Non-steroidal anti-inflammatory agents: drugs and mechanisms
Use of simple analgesics: paracetamol: NSAIDs
Opioids: drugs and mechanisms
Opioids: intramuscular, intravenous infusion, intravenous PCA, subcutaneous PCA, epidural, intrathecal
Regional local anaesthetic techniques: lumbar epidural, caudal epidural, simple peripheral nerve blocks
Local anaesthetic agents: drugs and mechanisms
Inhalational analgesia
Specific clinical groups: children, elderly, impaired consciousness, intensive care
Organisation and objectives of an acute pain service
Contributing to an acute pain service


Communication with patients, relatives, staff
Rapid response to unrelieved pain
Management tempered by awareness of potential complications and side-effects
Awareness of limitations in pain management
Making efforts to follow patients up on the wards
Recognition of need for team approach and partnerships in a pain team


Universal precautions and good working practices (hand washing, gloves etc)
Cross-infection: modes and common agents
Emergence of resistant strains: antibiotic policies in a hospital
Common surgical infections: antibiotic choice and prophylaxis
Infections from contaminated blood
Hepatitis and HIV infections: modes of infection: natural history: at-risk groups
Immunisation policy
Sterilisation of equipment
Strategy if contaminated
Preoperative assessment: awareness of at-risk groups
Recognition of the immunocompromised patient
Administration of IV antibiotics: risk of allergy and anaphylaxis
Aseptic techniques
Use of disposable filters and breathing systems
Use of protective clothing/gloves/masks etc


Every patient entitled to the best care available
Prevention of self-infection
Prevention of cross-infection

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